Judith S. Shaw

Health Literacy and Child Health Promotion: Implications for Research, Clinical Care, and Public Policy

The nations leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.

Improving Newborn Preventive Services at the Birth Hospitalization: A Collaborative, Hospital-Based Quality-Improvement Project

OBJECTIVE. The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization. METHODS. All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital. RESULTS. Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of ≥20% in ≥1 newborn preventive service. CONCLUSIONS. A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.

Strict interpretation of vaccination guidelines with computerized algorithms and improper timing of administered doses

Background. Frequently changing immunization recommendations may lead to incorrectly administered doses. Objective. To determine the incidence and characteristics of inappropriately timed vaccinations. Methods. Prospectively collected immunization histories of patients <5 years old from well-child care encounters with pediatric residents in a large urban clinic during a 3-month study period. New patients or those with no immunization history in the medical record were excluded. Paper records were verified before each visit and served as the immunization history. Immunization records were entered into and analyzed by the Massachusetts Immunization Information System with strict interpretation of minimum spacing and age guidelines to identify invalid vaccine doses. Reasons for invalidity were determined by manual review. Invalid doses were cross-referenced with clinic schedule to determine who delivered doses. Results. Inclusion criteria were met by 690 encounters. Charts were available for review before the encounter for 580, containing 6983 total immunizations. Of these 289 (4.1%) administered doses were invalid; 206 of 580 (35.5%) patients had at least one invalid dose. Common invalid doses given were unnecessary poliovirus vaccine around 18 months (n = 66) and second hepatitis B vaccine given too soon after the first (n = 53). All types of providers gave invalid doses; pediatric residents and fellows delivered significantly more (P < 0.01). Conclusions. By strict interpretation of immunization guidelines, many patients were immunized incorrectly. Clinicians should be aware of common errors in vaccine dosing and national guidelines should be simplified.

Improvement in Adolescent Screening and Counseling Rates for Risk Behaviors and Developmental Tasks

BACKGROUND: High-quality preventive services for youth aged 11 to 18 include assessment and counseling regarding health behavior risks and developmental tasks/strengths of adolescence. Nationally, primary care health behavior risk screening and counseling rates lag consid-erably behind other preventive health services. The purpose of this project was to assist pediatric and family medicine practices to make office systems–based changes that promote comprehensive screening and counseling for risks and developmental tasks/strengths during adolescent preventive services visits. METHODS: Over a 9-month period, 7 pediatric and 1 family medicine primary care practices (13 physicians and 3 nurse practitioners) participated in a modified Breakthrough Series Collaborative. This project was designed to support primary care practitioner efforts to implement comprehensive screening and counseling for risk behaviors and developmental tasks/strengths for their adolescent patients and increase the rate of brief office intervention and referral. Composite variables were designed to reflect whether screening and counseling were documented for risks and developmental tasks. Statistical comparisons were made by using the nonparametric Wilcoxon matched-pairs signed rank test. RESULTS: There were increases in the composite measures of screening and counseling for risk behaviors (all 6 risks: 26%–50%, P = .01) and 3 of 4 developmental tasks/strengths (32%–66%, P = .01). Documentation of office interventions for identified risks and out-of office referral rates did not change. CONCLUSIONS: With the use of an office systems–based approach, screening and counseling for all critical risk behaviors and developmental tasks/strengths during adolescent preventive services visits can be improved in primary care practices.

The National Improvement Partnership Network: State-Based Partnerships That Improve Primary Care Quality

Improvement partnerships (IPs) are a model for collaboration among public and private organizations that share interests in improving child health and the quality of health care delivered to children. Their partners typically include state public health and Medicaid agencies, the local chapter of the American Academy of Pediatrics, and an academic health care organization or childrens hospital. Most IPs also engage other partners, including a variety of public, private, and professional organizations and individuals. IPs lead and support measurement-based, systems-focused quality improvement (QI) efforts that primarily target primary care practices that care for children. Their projects are most often conducted as learning collaboratives that involve a team from each of 8 to 15 participating practices over 9 to 12 months. The improvement teams typically include a clinician, office manager, clinical staff (nurses or medical assistants), and, for some projects, a parent; the IPs provide the staff and local infrastructure. The projects target clinical topics, chosen because of their importance to public health, local clinicians, and funding agencies, including asthma, attention-deficit/hyperactivity disorder, autism, developmental screening, obesity, mental health, medical home implementation, and several others. Over the past 13 years, 19 states have developed (and 5 are exploring developing) IPs. These organizations share similar aims and methods but differ substantially in leadership, structure, funding, and longevity. Their projects generally engage pediatric and family medicine practices ranging from solo private practices to community health centers to large corporate practices. The practices learn about the project topic and about QI, develop specific improvement strategies and aims that align with the project aims, perform iterative measures to evaluate and guide their improvements, and implement systems and processes to support and sustain those improvements. Since 2008, IPs have offered credit toward Part 4 of Maintenance of Certification for participants in some of their projects. To date, IPs have focused on achieving improvements in care delivery through individual projects. Rigorous measurement and evaluation of their efforts and impact will be essential to understanding, spreading, and sustaining state/regional child health care QI programs. We describe the origins, evolution to date, and hopes for the future of these partnerships and the National Improvement Partnership Network (NIPN), which was established to support existing and nurture new IPs.

Parental alcohol screening in pediatric practices.

OBJECTIVES. Pediatricians are in an ideal position to screen parents of their patients for alcohol use. The objective of this study was to assess parents’ preferences regarding screening and intervention for parental alcohol use during pediatric office visits for their children. METHODS. A descriptive multicenter study that used 3 pediatric primary care clinic sites (rural, urban, suburban) was conducted between June 2004 and December 2006. Participants were a convenience sample of consecutively recruited parents who brought children for medical care. Parents completed an anonymous questionnaire that contained demographics; 2 alcohol-screening tests (TWEAK and Alcohol Use Disorders Identification Test); and items that assessed preferences for who should perform alcohol-screening, acceptance of screening, and preferred interventions if the screening result was positive. RESULTS. A total of 929 of 1028 eligible parents agreed to participate, and 879 of 929 completed surveys that yielded sufficient data for analysis. Most participants were mothers. A total of 101 of 879 parents screened positive on either the TWEAK or the Alcohol Use Disorders Identification Test. Parents with a negative alcohol screen (alcohol-negative) were more likely than parents with a positive alcohol screen (alcohol-positive) to report that they would agree to being asked about their alcohol use. There were no significant differences in preferences within alcohol-positive and alcohol-negative groups for screening by the pediatrician or computer-based questionnaire. Most preferred interventions for the alcohol-positive group were for the pediatrician to initiate additional discussion about drinking and its effect on their child, give educational materials about alcoholism, and refer for evaluation and treatment. Alcohol-positive men were more accepting than alcohol-positive women of having no intervention. CONCLUSIONS. A majority of parents would agree to being screened for alcohol problems in the pediatric office. Regardless of their alcohol screen status, parents are accepting of being screened by the pediatrician, a computer-based questionnaire, or a paper-and-pencil survey. Parents who screen positive prefer that the pediatrician discuss the problem further with them and present options for referral.

Improving Delivery of Bright Futures Preventive Services at the 9- and 24-Month Well Child Visit

OBJECTIVES: To determine if clinicians and staff from 21 diverse primary care practice settings could implement the 2008 Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd edition recommendations, at the 9- and 24-month preventive services visits. METHODS: Twenty-two practice settings from 15 states were selected from 51 applicants to participate in the Preventive Services Improvement Project (PreSIP). Practices participated in a 9-month modified Breakthrough Series Collaborative from January to November 2011. Outcome measures reflect whether the 17 components of Bright Futures recommendations were performed at the 9- and 24-month visits for at least 85% of visits. Additional measures identified which office systems were in place before and after the collaborative. RESULTS: There was a statistically significant increase for all 17 measures. Overall participating practices achieved an 85% completion rate for the preventive services measures except for discussion of parental strengths, which was reported in 70% of the charts. The preventive services score, a summary score for all the chart audit measures, increased significantly for both the 9-month (7 measures) and 24-month visits (8 measures). CONCLUSIONS: Clinicians and staff from various practice settings were able to implement the majority of the Bright Futures recommended preventive services at the 9- and 24-month visits at a high level after participation in a 9-month modified Breakthrough Series collaborative.

Effects of Patient-centered Medical Home Transformation on Child Patient Experience

Introduction: Patient experience, 1 of 3 aims for improving health care, is rarely included in studies of patient-centered medical home (PCMH) transformation. This study examines the association between patient experience and National Committee on Quality Assurance (NCQA) PCMH transformation. Methods: This was a cross-sectional study of parent-reported child patient experience from PCMH and non-PCMH practices. It used randomly sampled experience surveys completed by 2599 patients at 29 pediatric and family medicine PCMH (n = 21) and non-PCMH (n = 8) practices in Vermont from 2011 to 2013. Patient experiences related to child development and prevention were assessed using the Consumer Assessment of Health care Providers and Systems (CAHPS). Results: A 10-point increase in NCQA score at PCMH practices is associated with a 3.1% higher CAHPS child prevention score (P = .004). Among pediatric practices, PCMH recognition is associated with 7.7% (P < .0005) and 7.2% (P < .0005) higher CAHPS child development and prevention composite scores, respectively. Among family medicine practices, PCMH recognition is associated with 7.4% (P = .001) and 11.0% (P < .0005) lower CAHPS child development and prevention composite scores, respectively. Conclusions: Our results suggest that PCMH recognition may improve child patient experience at pediatric practices and worsen experience at family medicine practices. These findings warrant further investigation into the differential influence of NCQA PCMH transformation on family medicine and pediatric practices.

Pediatric-Informed Facilitation of Patient-Centered Medical Home Transformation

Patient-centered medical home (PCMH) transformation has been challenging for pediatric practices, in part because of the National Committee for Quality Assurance (NCQA) PCMH focus on conditions and processes specific to adult patients. Realizing the potential challenges faced by pediatric practices, Vermont supported pediatric-informed facilitators to help practices during PCMH transformation. This study characterizes the impact of pediatric-informed facilitators; provides benchmark data on NCQA scores, number of facilitation meetings, and the time between facilitation start and end; and compares pediatric- and adult-serving practices. We found no difference between pediatric and matched adult-serving practices in NCQA score, number of facilitation meetings, or weeks to NCQA scoring. These results suggest that pediatric-informed facilitators can help pediatric practices achieve NCQA PCMH recognition on par with practices serving adult patients. Supporting primary care practices with specialty-informed facilitators can assist integration into health care reform efforts.

Providing Health Supervision to Support High-Quality Primary Care: The Time is Now

From the Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vt The authors are the editors of Bright Futures: Health Supervision Guidelines for Infants, Children and Youth, Third Edition. Address correspondence to Judith S. Shaw, EdD, MPH, RN, University of Vermont College of Medicine, N329 Courtyard at Given, 89 Beaumont Ave, Burlington, Vermont 05405 (e-mail: judith.shaw@uvm.edu).